Provider Demographics
NPI:1598876773
Name:TODD-HOUSTON, GWENDOLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:
Last Name:TODD-HOUSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 NASSAU STREET
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403
Mailing Address - Country:US
Mailing Address - Phone:843-722-4112
Mailing Address - Fax:843-722-4802
Practice Address - Street 1:51 NASSAU ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5513
Practice Address - Country:US
Practice Address - Phone:843-722-4112
Practice Address - Fax:843-577-8960
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCL3207208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAT0221Medicaid
AT0221Medicare UPIN